The liver is the largest internal organ of the body. It is located on the right side behind the right lung and is protected by the lower ribcage. The liver performs many functions that are necessary for survival. The liver stores nutrients and vitamins absorbed by the intestines. It also metabolizes other nutrients so the body can use them for energy or to build and repair tissues.

Several types of tumors, both benign (non-cancerous) and malignant (cancerous) can develop in the liver. The most common type of liver cancer is hepatocellular carcinoma (HCC). It accounts for 84% of primary liver cancers (cancer that originates in the liver). The remaining pages will refer to HCC unless otherwise noted.

The liver can also develop metastatic or secondary tumors. These tumors have spread from cancer in another part of the body, like the breast or the pancreas. This is not called "liver cancer;" it’s named for the part of the body where the cancer originated (i.e. metastatic breast cancer). In the United States, metastatic liver tumors are more common than primary liver cancer.

Liver cancer is difficult to detect and, unfortunately, is usually not discovered until it has reached later stages, making it difficult to remove by surgery and cure. The liver’s placement in the body makes it impossible for physicians or patients to feel small liver tumors. HCC also spreads fairly quickly.

• Unexplained weight loss

• Anorexia (persistent lack of appetite)

• Early satiety (feeling very full after a small meal)

• Persistent abdominal pain

• Increasing abdominal girth (swelling of the "stomach" area) with or without breathing difficulty

• Sudden jaundice (yellow-green coloration of the skin andeyes) with no apparent reason

• Dramatic change in the overall condition of a patient with chronic hepatitis or cirrhosis

• Liver enlargement or a mass that can be felt in the area of the liver

Most of these symptoms are non-specific, and may be caused by other cancers or less serious conditions. The only way to find out is to receive a medical evaluation. The sooner the symptoms are diagnosed, the sooner appropriate treatments can begin and the more affective treatment is likely to be.

If liver cancer is suspected, the doctor will conduct a physical examination and a medical history. During a medical history, the patient will be asked questions about incidence of cancer in his/her family and other possible risk factors. Further tests help a doctor determine if cancer is causing symptoms. Some tests may include:

Alpha-fetoprotein (AFP) blood test: about 50 to 70% of people with primary liver cancer have elevated levels of AFP, so this can be helpful in diagnosing cancer. However, other cancers can also cause elevated levels, so this test is not very helpful in narrowing diagnosis to liver cancer.

Ultrasonography (ultrasound): images created by bouncing sound waves through the body and recording their echoes on a computer. Liver tumors can produce different echoes from normal liver tissue. Benign and malignant tumors also produce different echoes.

Computed tomography (CT): cross-sectional x-rays put together by a computer

Magnetic resonance imaging (MRI): the patient is placed in a magnetic field that can be used to produce images on a computer. It can produce more detailed images than an ultrasound or a CT scan, but this level of precision is not always necessary to evaluate liver cancer.

Angiography: x-rays taken of blood vessels

Laparoscopy: a thin, lighted tube with a lens is inserted through a small incision in the abdomen to view the liver and other nearby organs. Doctors can also take small tissue samples during this procedure.

Biopsy: this is the only way physicians can determine if a tumor is cancerous. Biopsies can be performed surgically, removing all or part of the tumor. However, doctors usually prefer to use procedures like laparoscopy or needle biopsies (a thin needle guided through the tissues over the liver without making a surgical incision) to determine information about the tumor before performing major surgery to remove it. The tissue is analyzed under a microscope to determine if it is cancerous.

Risk Factors
A risk factor is anything that increases a person’s chance of getting a specific disease. Cancer risk factors vary depending on the type of cancer. Doctors and researchers have discovered several risk factors for liver cancer:

• Viral hepatitis: researchers have linked to infection of hepatitis-B virus (HBV) and hepatitis-C virus (HCV) with the development of liver cancer. It is estimated that 10 to 20% of people with HBV will develop liver cancer, and HBV is present in about one fourth of cases of liver cancer in the United States.

• Exposure to aflatoxin: this is a carcinogenic (cancer causing) substance that can be found in molds that may contaminate peanuts, corn, grains and seeds. In tropical and subtropical regions measures have been taken to change and improve storage in order to reduce exposure to aflatoxins.

• Cirrhosis: the National Cancer Institute estimates that 5 to 10 percent of people with cirrhosis of the liver (a progressive disorder which leads to scarring of the liver) will develop liver cancer. Cirrhosis caused by viral hepatitis B and C, alcohol abuse, and certain genetic disorders puts people at higher risk for developing liver cancer.

• Exposure to vinyl chloride and thorium dioxide (Thorotrast): Exposure to these chemicals is more likely to cause angiosarcoma of the liver, a different type of cancer than HCC. They increase the risk of developing HCC to a far lesser degree.

• Birth control pills: types of oral contraceptives used in the past were linked to some variations of liver cancer, but rarely to HCC. Most of these types of oral contraceptives are no longer available, and it is unknown if those now in use increase risk for HCC.

• Anabolic steroids: Long term steroid use can slightly increase the risk for liver cancer.

• Arsenic: In some parts of the world, drinking water contaminated with arsenic causes increased risk for developing liver cancer.

Worldwide, viral hepatitis-B and -C are the most significant risk factors for liver cancer, so getting children vaccinated against hepatitis-B (there is not yet a vaccine for hepatitis-C) is a good way to aid in prevention. HBV and HCV can be spread through blood transfusions, by sharing needles, and by having unprotected sexual intercourse, so awareness of this disease and how to prevent it can in turn lower liver cancer risk. Alcohol abuse can lead to cirrhosis of the liver, which can lead to liver cancer, so drinking alcohol responsibly may help in prevention.

Liver cancer is difficult to treat unless it is found in early stages, when it is still small and hasn’t spread very far. Even if curing the cancer is not an option, treatment may be given to ease symptoms. Liver cancer can be treated with surgery, chemotherapy and/or radiation therapy. Sometimes physicians use more than one of these methods to best treat the disease.

Surgery is the only way to cure liver cancer. Surgery can only be performed if the cancer has not spread very far, and if the liver tissue is healthy. If the tissue is unhealthy due to cirrhosis, which is present in about 30% of HCC cancer cases in the United States, even the removal of a small amount of tissue around the tumor can leave too little healthy tissue left for proper liver function. The side effects of surgery depend on the extent of the operation, the patient’s general health, and other factors. Pain for the first few days after surgery is to be expected, but it can be controlled with medicine. People should feel free to discuss pain relief with the doctor or nurse.

Ablation is local therapy that treats a tumor without removing it. Examples of ablation are cryosurgery (destroying the tumor by freezing it with a very cold metal probe) and ethanol ablation (injecting alcohol directly into the tumor to kill the cancer cells). Ablation is a good method of treatment for patients with multiple cancers or health conditions (like cirrhosis or hepatitis B or C) that would make surgery risky. Doctors can cut off the blood supply to the cancer by blocking certain arteries, but this, like surgical removal of the tumor, is often impossible if the patient’s liver tissue is not healthy.

Chemotherapy is the use of anti-cancer drugs to destroy tumors. Chemotherapy is usually injected intravenously or taken orally. This is an example of systemic therapy, or treatment that travels through the blood stream and affects all parts of the body. Because it affects the whole body, it is useful for treating metastasized cancers of the liver. Chemotherapy damages rapidly dividing cells, like cancer cells. Unfortunately, other cells in the body, like hair follicle cells, cells lining the digestive tract, and blood-producing cells of bone marrow are also affected by chemotherapy, causing hair loss, nausea and vomiting, mouth sores, bruising and bleeding, increased chance of infection, and fatigue. Doctors can alleviate some of these symptoms with medication, so patients with side effects should inform their cancer care team.

Recently, hepatic artery infusion has been studied as a treatment for HCC. This is a type of regional chemotherapy, in which drugs are injected directly into the artery that supplies blood to the liver. A pump can be implanted to give medication when it is needed. This treatment minimizes other side effects and allows high doses of the medication to reach the cancer.

Radiation therapy, or radiotherapy, is the use of high-energy rays aimed at the cancer to destroy or shrink it. This treatment is not often used because the entire liver, not just the tumor, is negatively effected by the radiation, and no real effect on survival has been shown. The usual side effects for radiation therapy are sunburn-like skin changes and fatigue.

Your physician may recommend that you undergo a procedure-treatment directly into the liver called Hepatic Arterial Chemo-embolization (HACE). The procedure treatment is a one time event during your entire stay in the hospital.

1. What is liver cancer?

   The liver is the largest internal organ of the body. It is located on the right side behind the right lung and is protected by the lower ribcage. The liver performs many functions that are necessary for survival. Several types of tumors, both benign (non-cancerous) and malignant (cancerous) can develop in the liver. The most common type of liver cancer is hepatocellular carcinoma (HCC). It accounts for 84% of primary liver cancers (cancer that originates in the liver). The liver can also develop metastatic or secondary tumors. These tumors have spread from cancer in another part of the body, like the breast or the pancreas. This is not called "liver cancer;" it’s named for the part of the body where the cancer originated (i.e. metastatic breast cancer). In the United States, metastatic liver tumors are more common than primary liver cancer.

2. What are the causes and risk factors for liver cancer?