Signs, Symptoms, Stages, and Treatment

Liver cancer is a type of cancer in which cells in the liver grow and divide too fast. These cells can invade nearby tissues and spread to other parts of your body. There is more than one type of liver cancer.

Liver cancer that begins in the liver is called primary liver cancer. Cancer that starts elsewhere and spreads (metastasizes) to your liver is more common.

A liver metastasis, the spread of cancer cells to the liver, contains the same type of cancer cells as the primary tumor. Breast cancer that spreads to your liver is called metastatic breast cancer, not liver cancer.

While there is no known cause for liver cancer, there are several known risk factors. There are many options for treatment, though. Tumor size and location affect your choices for treatment.

This article discusses liver cancer types, symptoms, causes, risk factors, diagnosis, and treatment.

Types of Liver Cancer

The five main types of primary liver cancer include the following:

• Hepatocellular carcinoma (HCC): HCC is the most common type of primary liver cancer. It begins in hepatocytes, the main liver cells that process nutrients in your blood. People with hepatocellular carcinoma often have a history of behaviors or conditions that cause liver inflammation or scarring, such as long-term hepatitis B or hepatitis C infections, nonalcoholic fatty liver disease, cirrhosis, or excessive alcohol consumption.
• Fibrolamellar carcinoma: Also called fibrolamellar-hepatocellular carcinoma (FLL-HCC), this is a rare type of hepatocellular carcinoma. It most often occurs in adolescents and young adults under 40 years old with no history of liver disease or other known risk factors. Fibrolamellar carcinoma is the least aggressive type of primary liver cancer.
• Cholangiocarcinoma (bile duct cancer): Cholangiocarcinoma is the second most common type of primary liver cancer. It starts in cells in your bile duct, tubelike structures that deliver bile from the liver to the gallbladder, where this liquid is stored to help in food digestion. Cholangiocarcinoma most often occurs in people who have had an infection with hepatitis B or C, primary sclerosing cholangitis (inflammation and scarring of the bile ducts), and nonalcoholic fatty liver disease.
• Liver angiosarcoma: This type develops along the inner linings of the blood and lymph cells. It frequently occurs in adults in their 60s and 70s, though it can also affect children. Liver angiosarcoma is a very aggressive form of liver cancer. About 30% of liver angiosarcoma cases are linked with risk factors related to the chemicals industries.
• Hepatoblastoma: Hepatoblastoma is a type of primary liver tumor made of tissue that forms in the liver. It is the most common type of liver cancer in children. It usually occurs in children before age 3. Hepatoblastoma may be cured in cases that involve a small tumor that can be completely removed by surgery.

Liver Cancer Symptoms

Many common symptoms of liver cancer are not unique to this disease. Most symptoms don’t appear until the later stages of the disease, when a liver tumor develops. Having your symptoms diagnosed early allows you to get treatment when it can be most effective.

Common symptoms of liver cancer include the following:

• Unexplained weight loss
• Loss of appetite
• Very full feeling after a small meal
• Pain in the upper abdomen (belly) on the right side or near the right shoulder blade
• Feeling of fullness or a mass under the ribs on the right side due to an enlarged liver
• Feeling of fullness or a mass under the ribs on the left side due to an enlarged spleen
• Nausea or vomiting
• Swelling or bloating in the abdomen
• Jaundice (yellowing of your skin and eyes)
• Itching
• Fever
• Enlarged veins on your abdomen
• Abnormal bruising or bleeding
• Dark urine
• Pale/chalky stools

Some liver tumors produce hormones that affect organs other than your liver. These hormones may cause the following symptoms, called paraneoplastic syndromes:

• Hypercalcemia (high blood calcium levels), which can trigger confusion, nausea, frequent urination, constipation, weakness, or muscle problems
• Hypoglycemia (low blood sugar levels), which can cause fainting or fatigue
• Erythrocytosis (high red blood cell count), also called polycythemia, which can cause facial flushing, redness, blurred vision, or nosebleeds
• Hypercholesterolemia (high cholesterol levels)
• Gynecomastia (male breast enlargement)
• Shrinking of the testicles, which can cause pain or swelling

What Causes Liver Cancer?

The specific causes of liver cancer are not known. Liver cancer occurs when a cell’s DNA changes so that it becomes cancerous. DNA contains the genes that tell cells how to grow, multiply, and die.

Abnormal liver cells begin to multiply uncontrollably and live longer than they should. These cancerous liver cells can spread into surrounding tissue and eventually travel to other parts of your body.

Liver cancer may have genetic or hereditary causes that you can’t control. However, you may be able to reduce your risk of developing liver cancer by understanding common risk factors and working to change the risk factors that you can to lower your chances of having the disease.

Risk Factors for Liver Cancer

Risk factors for liver cancer are behaviors, demographics, and physical characteristics that increase the possibility of developing liver cancer. Having risk factors doesn’t mean you will develop liver cancer, but it does make it more likely that it will occur. However, it is also possible to have liver cancer without having any known risk factors.

The following factors can increase your risk of developing liver cancer:

Having one of the following medical and genetic conditions may also increase your risk of liver cancer. These conditions include the following:

• Hereditary hemochromatosis (a genetic disease that causes excess iron buildup)
• Glycogen storage disease (a rare condition that interferes with the way our body uses and stores glycogen, a form of sugar or glucose)
• Alpha-1 antitrypsin deficiency (a genetic disease caused by a lack of the protective protein Alpha-1-antitrypsin)
• Porphyria cutanea tarda (a rare group of diseases that develop from problems with the process of creating blood cells)
• Wilson’s disease (a genetic disorder that results in excessive amounts of copper in your body)

How Is Liver Cancer Diagnosed?

Diagnosis of liver cancer usually involves a physical examination and one or more special medical tests.

Physical examination: A physical examination for liver cancer involves taking your medical history and family history, and discussing your symptoms. Your healthcare provider also looks for signs of lumps, bumps, swelling, or jaundice, which might indicate liver disease.

Blood tests: Certain blood tests can help in the diagnosis of liver cancer, including:

Imaging tests: The following imaging tests may be used to diagnose liver cancer:

Biopsy: A biopsy removes a tissue sample to test for cancer. The following types of biopsies can be used in diagnosing liver cancer:

• Needle biopsy: Inserts a hollow needle into your liver to extract the tissue sample
• Laparoscopic biopsy: Takes specimens during laparoscopy, using a fiber-optic instrument inserted through tiny incisions
• Surgical biopsy: Involves the removal of a piece of the tumor or the entire tumor for testing

Screening for Liver Cancer

Screening looks for indications of cancer in people who have no symptoms. This allows cancer to be detected early. People at average risk for liver cancer are not screened.

People at increased risk of liver cancer may be screened every six months with an alpha-fetoprotein blood test and ultrasound imaging. Conditions that elevate risk include cirrhosis, hereditary hemochromatosis, or chronic hepatitis B infection.

4 Stages of Liver Cancer

Cancer staging is a process that identifies how much liver cancer is in your body and where it is located at the time of your initial diagnosis. Your liver cancer’s initial staging category won’t change over time, even if your cancer improves or progresses. Rarely, cancer might be restaged after a period of remission.

In the United States, liver cancer is most often staged using the American Joint Committee on Cancer’s TNM system, which accounts for the following:

• Size and tumor number (T)
• Lymph node involvement (N)
• If and to what extent the liver cancer has metastasized (M)

The four stages of liver cancer range from stage 1, which is the least advanced stage, to stage 4, the most advanced stage. Stages of liver cancer include the following:

Stage 1A:

• Stage 1A involves a single tumor smaller than 2 centimeters (cm) across.
• Cancer has not spread outside the liver.

Stage 1B:

• Stage 1B involves a single tumor larger than 2 cm across.
• Cancer has not spread outside the liver.

Stage 2:

• Stage 2 involves a single tumor larger than 2 cm across that has grown into blood vessels or multiple tumors smaller than 5 cm across.
• Cancer has not spread outside the liver.

Stage 3A:

• Stage 3A involves multiple tumors, with one or more tumors larger than 5 cm across.
• Cancer has not spread outside the liver.

Stage 3B:

• Stage 3B involves one or more tumors of any size in the portal vein (a large vein in the liver).
• Cancer has not spread outside the liver.

Stage 4A:

• Stage 4A involves one or more tumors of any size that spread to nearby lymph nodes.
• Other areas of the body are not involved.

Stage 4B:

• Stage 4B involves one or more tumors of any size that metastasized to other areas of the body, affecting other organs.
• Lymph nodes may or may not be involved.

Liver Cancer Treatment

Your liver cancer treatment is determined by several factors, including your stage of liver cancer and the health of your liver. Other considerations like side effects of treatment, other medical conditions, and the chances of treatment curing the disease or relieving symptoms can impact your options.

Surgery

Surgery is regarded as the best treatment option for liver cancer.

Liver Resection Surgery

This surgery is called a partial hepatectomy or liver resection. It involves surgically removing the portion of the liver affected by cancerous tumors while leaving the healthy sections of the liver to perform normal liver functions.

Surgery is reserved for people with early-stage primary liver cancer whose tumors are limited to one area of the liver and have not spread to other areas. Surgical candidates must also have healthy liver function so the remaining portion of their liver can maintain normal operation after surgery.

People with liver cirrhosis may not be good candidates for liver surgery. To qualify for surgery, you must have at least 30% of liver function left after the tumor is removed. The liver can regrow to its normal size and function if it is healthy enough.

Minimally Invasive Liver Surgery

Minimally invasive liver surgery is performed with small incisions. It reduces side effects and recovery time. Laparoscopic hepatectomy is a liver resection performed laparoscopically, using a laparoscope, a long tool with a tiny video camera and a light on the end. The tool is inserted through the small incisions to reach your liver.

Liver Transplant Surgery

Liver transplant surgery involves removing the entire diseased liver and replacing it with a healthy donor liver. When a donor liver is available, this type of surgery is reserved for people who have liver cancer with all the following characteristics:

• Tumors that are small in size and number
• Tumors that haven’t spread to nearby blood vessels
• Liver unaffected by cirrhosis or another liver condition

Radiation Therapy

Radiation therapy uses high-powered waves to break down and destroy the genetic material (DNA) inside liver cancer cells. It focuses radiation on cancer from a source outside the body. Radiation therapy can also relieve discomfort due to an enlarged liver or spleen.

One form of radiation therapy called radioembolization injects small radioactive beads into the hepatic artery, the main vessel that carries blood to the liver. The beads lodge in the liver near the tumor and release small amounts of radiation that travel only a short distance to relieve symptoms.

Chemotherapy

Chemotherapy involves using drugs that destroy tumor cells in different ways. A combination of two or three drugs can destroy or slow the progression of cancer cells.

Chemotherapy is usually administered orally or by injection. However, chemotherapy for liver cancer may be administered via hepatic artery infusion. This technique uses a pump connected to your liver to deliver drugs directly into the liver through your hepatic artery.

Immunotherapy

Immunotherapy uses drugs to enhance the natural reaction of your immune system to fight liver tumor cells. Six immunotherapy drugs are approved by the Food and Drug Administration (FDA) for liver cancer. They include the following:

Localized Treatments

Localized treatments are administered directly to the liver cancer cells. Localized treatments for liver cancer include the following:

• Radiofrequency ablation: High-energy radio waves heat and destroy cancer cells using a needlelike probe into the tumor through the skin.
• Cryotherapy: Very cold gasses are passed through the tumor to freeze the cancer cells, causing them to die.
• Microwave ablation: Heat from microwaves is transmitted into cancer cells.
• Ethanol (alcohol) ablation: Concentrated alcohol is injected directly into the tumor to damage liver tumor cells.
• Embolization therapy: Substances are injected directly into an artery in the liver to block or reduce blood flow to a liver tumor.

Targeted Drug Therapy

Targeted drug therapy interferes with substances needed for cancer to grow. These drugs can destroy cancer cells without harming healthy cells. Targeted drug therapy is used for liver cancer that has spread to other organs. It can also treat tumors too large for surgery or those too close to vital blood vessels.

The following drugs are used in targeted drug therapy for liver cancer:

• Nexavar (sorafenib)
• Lenvina (lenvatinib)
• Stivarga (regorafenib)
• Cabometyx (cabozantinib).
• Avastin (bevacizumab)
• Cyramza (ramucirumab)

Can You Prevent Liver Cancer?

While it’s not possible to prevent liver cancer, you can take steps to reduce your risk of getting diseases known to make your liver vulnerable to liver cancer.

Hepatitis B Vaccine

The hepatitis B vaccine is the best way to prevent hepatitis B, a viral infection of the liver that can lead to cirrhosis, liver failure, and liver cancer. The Centers for Disease Control and Prevention (CDC) advises the hepatitis B vaccine for the following groups:

• All infants
• All children and adolescents younger than 19 years who have not been vaccinated
• Adults aged 19 through 59 years
• Adults age 60 years and older who have known risk factors for hepatitis B

The vaccine may also be administered to adults age 60 and older who do not have known risk factors for hepatitis B.

Reduce the Risk of Hepatitis C

While there is no vaccine for hepatitis C, you can reduce your risk of getting the disease by taking the following steps to avoid behaviors known to transmit the virus:

• Avoid injecting drugs with unsterile injection equipment.
• Avoid sharing personal care items that could have blood on them (razors, toothbrushes, nail clippers).
• If you are a healthcare or public safety worker, follow universal blood/body fluid precautions for handling needles and other sharps.

If you are at risk of having hepatitis C, get tested. Treatments can cure most cases of hepatitis C in eight to 12 weeks.

Prevent Cirrhosis

You can help prevent cirrhosis, a leading risk factor for liver cancer, by managing the factors that contribute to cirrhosis in the following ways:

• Do not drink alcohol.
• Get vaccinated against hepatitis B.
• Take steps to prevent getting hepatitis C.
• Establish and maintain a healthy weight.
• Use a condom with every sexual interaction.
• Stop smoking.
• Do not share needles or syringes during injection drug use.

Liver Cancer Prognosis

Your liver cancer prognosis describes your likely outcome from cancer and cancer treatment. However, it’s important to remember that your prognosis is simply a calculated guess based on the experiences of large groups of people over many years.

Your prognosis depends on the following factors:

• Cancer type and location
• The extent of liver cancer present
• Your overall health
• Your treatment preferences
• The way your cancer responds to treatment

Survival rates tend to be best for people who have liver cancer found and treated in its earliest stages. The five-year survival rate for liver cancer in the United States is about 17%. However, when cancer is found before it spreads, the five-year survival rate for liver cancer is 31%.

Survival statistics do not represent individual cases. Discuss your prognosis with your healthcare provider.

Living With Liver Cancer: Support and Resources

While the physical aspects of living with liver cancer can be devastating, maintaining your overall emotional and mental wellness can be just as overwhelming. These challenges begin with your diagnosis and extend through your treatment and years into your survivorship.

Though you may feel alone, your healthcare provider can offer guidance in determining where to find the support you need. Don’t hesitate to accept support from family and friends who can assume caregiving roles when you need an extra hand.

Seek support from others in online or local, in-person cancer support groups. Follow social media, blogs, and podcasts that can educate you about your condition.

The following organizations provide resources that range from patient education to cancer support groups:

Summary

Liver cancer includes cancers that affect your liver and bile ducts. Liver cancer can start in liver cells. More often, it occurs when cancer cells move to your liver from cancer in another part of your body.

While the exact cause of liver cancer isn’t clear, reducing known risk factors for liver cancer can help you prevent this disease. Keeping a healthy liver by avoiding cirrhosis and hepatitis B and C can lessen your risk of liver cancer.

Treatments for liver cancer vary based on the type of cancer you have and other unique factors about your health and disease. Starting treatment early can help you get the best outcomes. Consult with your healthcare provider if you’re at high risk for liver cancer so you can observe your liver health and catch problems early.