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Liver Cancer - Overview

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Liver Cancer. To see other pages, use the menu on the side of your screen. Think of that menu as a roadmap to this full guide.

About the liver

The liver is the largest internal organ in the body, and its functions are essential for the digestion of food. No one can survive without a liver. Functions of the liver include:

  • Collecting and filtering blood from the intestines
  • Processing and storing needed nutrients absorbed by the intestines
  • Chemically changing (metabolizing) some nutrients into energy or to repair and build tissue
  • Producing some of the body’s blood clotting factors
  • Removing toxins from the body
  • Helping maintain the proper sugar level in the body

Types of liver cancer

Cancer begins when normal cells change and grow uncontrollably, forming a mass called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can spread to other parts of the body. A benign tumor means the tumor will not spread.

Primary liver cancer is cancer that begins in the liver. It is more common for the liver to be the site of metastasis (spread) of a cancer that started in another place, such as pancreatic, colon, stomach, breast, or lung cancer. However, these are not primary liver cancer. For more information about cancer that started in another part of the body and has spread to the liver, read about that specific cancer type.

This section only covers adult primary liver cancer. The subtypes of adult primary liver cancer are named for the type of cell from which they develop. These subtypes are described below.

Types of adult primary liver cancer

Type of Liver Cancer

Description

How Common

Hepatocellular carcinoma (HCC)

Hepatocellular carcinoma can have different growth patterns. Some spread tentacle-like growths through the liver. This pattern is the most common one in the United States. Some start as a single tumor that spreads to other parts of the liver as the disease develops. Others develop as nodules at several different places in the liver. Occasionally, a pattern isn't clear.

Approximately 80% of adult primary liver cancers are hepatocellular carcinomas.

Cholangiocarcinoma
(also called bile duct cancer)

Cholangiocarcinomas grow from cells in the bile duct of the liver. The bile duct is a thin tube that extends from the liver to the small intestine. The bile duct starts inside the liver as several smaller tubes that join together.

About 10% to 20% of adult primary liver cancers are cholangiocarcinomas.

Angiosarcoma

Angiosarcoma starts in the blood vessels of the liver and grows very quickly.

About 1% of adult primary liver cancers are angiosarcomas.

The remainder of this section discusses the most common type of adult primary liver cancer, hepatocellular carcinoma (HCC).

Looking for More of an Overview?

If you would like additional introductory information, explore these related items. Please note these links take you to other sections on Cancer.Net:

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Liver Cancer - Statistics

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find information about how many people learn they have this type of cancer each year and some general survival information. Remember, survival rates depend on several factors. To see other pages, use the menu on the side of your screen.

This year, an estimated 33,190 adults (24,600 men and 8,590 women) in the United States will be diagnosed with primary liver cancer. An estimated 23,000 deaths (15,870 men and 7,130 women) from this disease will occur this year. Liver cancer is the tenth most common cancer and the fifth most common cause of cancer death among men, and the ninth most common cause of cancer death among women.

When compared to the United States, liver cancer is much more common in developing countries within Africa and East Asia. In some countries, it is the most common cancer type.

The five-year survival rate is the percentage of people who survive at least five years after the cancer is detected, excluding those who die from other diseases. Overall, the five-year survival rate of people with liver cancer is 16%. For the 41% of people who are diagnosed at an early stage, the five-year survival rate is 29%. If liver cancer has spread to surrounding tissues or organs and/or the regional lymph nodes, the five-year survival rate is 10%. If the cancer has spread to a distant part of the body, the five-year survival rate is 3%. However, even if the cancer is found at a more advanced stage, treatments are available that help many people with liver cancer experience a similar quality of life as before their diagnosis, at least for some period of time.

Cancer survival statistics should be interpreted with caution. These estimates are based on data from thousands of people with this type of cancer, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with liver cancer. Because the survival statistics are measured in five-year intervals, they may not represent advances made in the treatment or diagnosis of this cancer. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2014.

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Liver Cancer - Risk Factors and Prevention

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer. To see other pages, use the menu on the side of your screen.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors can raise a person’s risk of developing HCC. The main risks in the United States are cirrhosis of the liver and non-alcoholic fatty liver disease (NAFLD).

Viral hepatitis. Hepatitis viruses are viruses that infect the liver. Two common types are hepatitis B and hepatitis C. Chronic liver infection with the hepatitis B or hepatitis C virus is associated with less than half of liver cancers diagnosed in the United States; however, viral hepatitis is the largest risk factor for this type of cancer worldwide. People who have the hepatitis B virus face up to a 100-fold increased risk of developing HCC, although HCC usually develops several decades after such an infection starts.

Viral hepatitis can be passed from person to person through exposure to another person's blood or bodily fluids through injury, by sharing needles during drug use, or by sexual contact. In the case of hepatitis B, an unborn baby or infant can get the virus if the mother has it, although this can be avoided by vaccinating the baby. If you develop acute hepatitis B or C and then “clear the virus,” you have no increased risk of liver cancer. Only people who don’t clear the virus, known as “carriers,” have an increased risk. Your doctor will be able to perform blood tests that tell if you have cleared the virus.

Cirrhosis. Cirrhosis develops when liver cells are damaged and are replaced by scar tissue. Most cirrhosis in the United States is caused by alcohol abuse. Other causes are viral hepatitis (types B and C, as mentioned above), too much iron in the liver from a disease called hemochromatosis, and some other rare types of chronic liver disease.

Obesity, NAFLD, and diabetes. Obesity causes fat to be deposited in the liver, which leads to a condition known as NAFLD. Over the past decade, strong evidence has emerged suggesting that NAFLD and diabetes, a related disorder, are increasingly important risk factors for HCC in the United States. 

Age. In the United States, adult primary liver cancer occurs most often in people older than 60.

Gender. Men are more likely than women to develop this type of cancer.

Environmental factors. Some environmental factors may increase the risk of liver cancer, such as exposure to certain chemicals or eating food contaminated with aflatoxin, a toxin made by a mold that can grow on stored nuts and grains. There is less risk of this in the United States.

Risk factors are cumulative, meaning that having more than one risk factor increases the risk even more. For instance, a person who carries both hepatitis B and C has a higher risk than a person carrying one type of the virus.

Prevention and Early Detection

Research continues to look into what factors cause liver cancer and what people can do to lower their personal risk. There is no proven way to completely prevent this disease, but there may be steps you can take to lower your cancer risk. Talk with your doctor if you have concerns about your personal risk of developing this type of cancer.

In the United States, HCC can usually be avoided by preventing viral hepatitis and cirrhosis. A vaccine can protect healthy people from contracting hepatitis B. In fact, the U.S. Centers for Disease Control and Prevention recommends that all children should have this vaccination. There is no vaccine against hepatitis C, which is most often associated with current or previous intravenous (IV) drug abuse. Blood banks in the United States check donated blood to make sure that blood carrying the hepatitis viruses is not used.

Cirrhosis can be avoided by not abusing alcohol and preventing viral hepatitis. Most industrialized countries have regulations to protect people from cancer-causing chemicals. In the United States, such regulations have virtually eliminated these chemicals as a cause of HCC.

There is increasing evidence that certain medications can control chronic hepatitis B or C infection, and thereby reduce the inflammation (swelling) these viruses cause in the liver. There have been major advances over recent years in anti-viral therapy, particularly for chronic hepatitis C virus infection. This is likely to have a major positive impact on liver cancer prevention, particularly if taken before cirrhosis develops. For information these types of treatments, it is important to talk with a hepatologist, a doctor who specializes in diseases of the liver.

Because NAFLD linked to obesity is becoming an increasingly important risk factor for HCC, people are also encouraged to follow established guidelines for good health, such as maintaining a healthy weight, eating a balanced diet, and participating in moderate physical activity. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level.

If you know you have cirrhosis or other risk factors, it is extremely important to talk with your doctor about whether you should be regularly screened for liver cancer. Finding a cancer before any symptoms have developed will increase the chance of successful treatment. Hepatologists are the doctors with the most experience in screening for primary liver cancer. You may also see the term “surveillance” used to explain this, but this means the same as screening.

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Liver Cancer - Symptoms and Signs

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. To see other pages, use the menu on the side of your screen.

People with HCC may experience no symptoms, particularly when the tumor is detected early as part of a screening program. When symptoms or signs do occur, they include:

  • Pain, especially at the top right of the abdominal area, or near the right shoulder blade or in the back
  • Unexplained weight loss
  • A hard lump under the ribs on the right side of the body, which could be the tumor or a sign that the liver has increased in size
  • Weakness or fatigue

When HCC is diagnosed, some people will already know that they have cirrhosis and will be receiving care from a doctor. Some symptoms experienced by patients with HCC may be caused by cirrhosis rather than the tumor. These symptoms include abdominal swelling from ascites (fluid accumulation) and needing more diuretics (water tablets) to control the fluid accumulation. Hepatic encephalopathy (mental confusion) and bleeding from the esophagus or stomach, or any worsening of the condition, may also indicate cancer.

If you are concerned about one or more of the symptoms or signs on this list, please talk with your doctor. Your doctor will ask how long and how often you’ve been experiencing the symptom(s), in addition to other questions. This is to help find out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about symptoms you experience, including any new symptoms or a change in symptoms.

The next section helps explain what tests and scans may be needed to learn more about the cause of the symptoms. Use the menu on the side of your screen to select Diagnosis, or you can select another section, to continue reading this guide.  

Liver Cancer - Diagnosis

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find a list of the common tests, procedures, and scans that doctors can use to find out what’s wrong and identify the cause of the problem. To see other pages, use the menu on the side of your screen.

Doctors use many tests to diagnose cancer and find out if it has spread to another part of the body, called metastasis. Some tests may also determine which treatments may be the most effective. Your doctor may consider these factors when choosing a diagnostic test:

  • Age and medical condition
  • Type of cancer suspected
  • Signs and symptoms
  • Previous test results

The following tests may be used to diagnose HCC. This list describes options for diagnosing this type of cancer, but not all tests listed will be used for every person.

Physical examination. If a person has symptoms of HCC, the doctor will feel the abdomen to check the liver, spleen, and other nearby organs for lumps, swelling, or other changes. The doctor will also look for an abnormal buildup of fluid in the abdomen and for signs of jaundice, which include yellowing of the skin and whites of the eyes.

Blood tests. At the same time as the physical examination, the doctor will most likely do a blood test to look for a substance called alpha-fetoprotein (AFP). In the United States, AFP is found in elevated levels in the blood of about 50% to 70% of people who have HCC. The doctor will also test the patient’s blood to see if he or she has hepatitis B or C. Other blood tests can show how well the liver is working.

In addition, other tests are commonly needed to diagnose HCC and to find where the tumor is located in the liver and if it has spread to other parts of the body. After the physical examination and blood tests, the doctor may recommend one or more of the following tests:

Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. The sound waves bounce off the liver, other organs, and tumors. Each creates a different picture on a computer monitor.

Computed tomography (CT or CAT) scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a pill to swallow. Often, HCC can be diagnosed based on features specific to the cancer that are seen on a CT scan. This helps patients avoid a liver biopsy (see below). A CT scan can also be used to measure the tumor’s size.

Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can also be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a pill to swallow.

Angiogram. An angiogram is an x-ray picture of the blood vessels. A dye is injected into the bloodstream so the blood vessels of the liver show up on an x-ray.

Laparoscopy. This test allows the doctor to see inside the body with a thin, lighted, flexible tube called a laparoscope. The person is sedated as the tube is inserted through a small incision in the abdomen. Local anesthetic to numb the area is also used.

Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. The sample removed during the biopsy is analyzed by a pathologist. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

The type of biopsy performed will depend on the location of the cancer. The biopsy can be done during a laparoscopy, a fine needle aspiration, or a core biopsy. During a fine needle aspiration, cells are removed using a thin needle inserted into the tumor. A core biopsy uses a thicker needle. Either procedure is done by a radiologist who uses an ultrasound to direct him or her to the particular part of the liver with the tumor. The actual biopsy procedure usually lasts for less than one minute. It is typically not painful, and few people have complications from the procedure.

Before the biopsy, your doctor will test your blood to make sure it clots normally to decrease the risk of bleeding after the procedure. Sometimes your doctor might perform a laparoscopy and biopsy to look at the non-cancerous part of the liver to find out if you have cirrhosis, which will help determine the best treatment options.

When the AFP blood test strongly indicates HCC, and other test results are typical of HCC, a biopsy may not be needed. Also, most surgeons will recommend that a biopsy be done as part of surgery if all or part of the liver is being removed, rather than as a separate procedure beforehand.

It is also important to note that, with newer imaging methods, very small masses are easier to find. However, it is not always possible to identify what a very small mass is and if it is cancer. In these instances, particularly when the mass is one centimeter or less in size, the doctor may recommend a “watch and wait” approach, also called active surveillance or watchful waiting. This means that the scans are repeated in three to six months. If the later scan shows that the size hasn’t changed, the surveillance approach is continued. If it grows, however, the doctor will then do a biopsy.

Molecular testing of the tumor. Your doctor may recommend running laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. Results of these tests will help decide whether your treatment options include a type of treatment called targeted therapy (see the Treatment Options section).

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer; this is called staging.

The next section helps explain the different stages for this type of cancer. Use the menu on the side of your screen to select Stages, or you can select another section, to continue reading this guide.  

Liver Cancer - Stages

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. To see other pages, use the menu on the side of your screen.

There are two types of liver cancer: primary and metastatic. Primary liver cancer begins in the liver; metastatic (secondary) liver cancer has spread to the liver from a cancer that started in another part of the body. For information about stages of secondary liver cancer, read about the primary type of cancer because there are different stage descriptions for different types of cancer. For example, lymphoma that has spread to the liver is still staged as lymphoma.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer's stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor decide what kind of treatment is best and can help predict a patient's prognosis, which is the chance of recovery.

For liver cancer, the staging information below is specifically for HCC and is based on whether a tumor is able to be surgically removed. When surgery is not an option, the doctor will use additional factors, such as overall liver function, to determine the treatment plan and predict prognosis.

Localized resectable. Cancer is only in one place in the liver, and the other part of the liver is healthy. The cancer is resectable, meaning it can be removed using surgery.

Localized unresectable. Cancer is found in only one part of the liver, but it cannot be removed by surgery. This makes the tumor "unresectable." A smaller tumor may not always be removable by surgery because the liver itself is seriously damaged, usually with cirrhosis, and there would not be enough of the liver left after the operation to keep a person healthy.

Advanced. Cancer has spread throughout the liver and/or to other parts of the body, such as the lungs and bones.

Recurrent. Recurrent cancer is cancer that has come back after treatment. If there is a recurrence, the cancer may need to be staged again (called re-staging) using the system above.

To describe the stage in more detail, doctors sometimes use the TNM system, outlined below. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:

  • How large is the primary tumor and where is it located? (Tumor, T)
  • Has the tumor spread to the lymph nodes? (Node, N)
  • Has the cancer metastasized to other parts of the body? (Metastasis, M)

The results are combined to determine the stage of cancer for each person. There are four stages: stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

This staging system is most useful for patients whose tumor can be surgically removed. Here are more details on each part of the TNM system for liver cancer.

Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. If there is more than one tumor, the lowercase letter “m” (multiple) is added to the “T” category. Specific tumor stage information for HCC is listed below.

TX: The primary tumor cannot be evaluated.

T0: There is no evidence of a primary tumor.

T1: The tumor is 2 centimeters (cm) or smaller. It does not involve nearby blood vessels.

T2: Either of these:

  • Any tumor that involves nearby blood vessels.
  • More than one tumor, but none larger than 5 cm.

T3a: There is more than one tumor, and at least one is larger than 5 cm.

T3b: The tumor (of any size) involves the major veins around the liver.

T4: Either of these:

  • The tumor has spread to the organs near the liver (except the gallbladder).
  • The tumor has broken through the visceral peritoneum (layer of tissue that lines the abdomen).

Node. The "N" in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the liver are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0: Cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional lymph nodes.

Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body.

MX: The tumor cannot be evaluated.

M0: The cancer has not spread to other parts of the body.

M1: The tumor has spread to another part of the body.

Cancer stage grouping

Doctors assign the stage of the HCC by combining the T, N, and M classifications.

Stage I: This is the earliest stage of HCC. The tumor has not spread to the blood vessels, lymph nodes, or other parts of the body (T1, N0, M0).

Stage II: The tumor involves nearby blood vessels, but it has not spread to the regional lymph nodes or other parts of the body (T2, N0, M0).

Stage IIIA: The cancer has not spread beyond the liver, but the area of the cancer is larger than stage I or II (T3a, N0, M0).

Stage IIIB: The cancer involves a major vein around the liver, but it has not spread to nearby lymph nodes or other parts of the body (T3b, N0, M0).

Stage IIIC: Any tumor that has spread to the organs near the liver (except the gallbladder), or if the tumor has broken through the visceral peritoneum. There is no spread to nearby lymph nodes or other parts of the body (T4, N0, M0).

Stage IVA: Any tumor that has spread to the regional lymph nodes but not to other parts of the body (any T, N1, M0).

Stage IVB: Any tumor that has spread to other parts of the body (any T, any N, M1).

TNM system outline used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Seventh Edition (2010) published by Springer-Verlag New York, www.cancerstaging.net.

Information about the cancer’s stage will help the doctor recommend a treatment plan.  The next section helps explain the treatment options for this type of cancer. Use the menu on the side of your screen to select Treatment Options, or you can select another section, to continue reading this guide.  

Liver Cancer - Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages, use the menu on the side of your screen.

This section outlines treatments that are the standard of care (the best proven treatments available) for HCC. When making treatment plan decisions, patients are also encouraged to consider clinical trials as an option. A clinical trial is a research study to test a new approach to treatment to evaluate whether it is safe, effective, and possibly better than the standard treatment. Clinical trials may test such approaches as a new drug, a new combination of standard treatments, or new doses of current therapies. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials and Latest Research sections.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team.

Treatment options and recommendations depend on several factors:

  • Whether the cancer is only in the liver
  • Whether the cancer is only in the area where it started or has spread widely throughout the liver
  • The patient’s preferences and overall health
  • The damage to the remaining cancer-free area of the liver

When a tumor is found at an early stage and the patient’s liver is working well, treatment is aimed at trying to successfully eliminate the cancer. Your care plan may also include treatment for symptoms and side effects, an important part of cancer care. When liver cancer is found at a later stage, or the patient’s liver is not working well, the patient and doctor should talk about the goals of each treatment recommendation. At this point, the goals of treatment may focus on slowing growth of the cancer and relieving symptoms to improve quality of life.

The various disease-directed treatment options can be grouped according to whether they may get rid of the cancer completely or are aimed mainly at increasing the patient’s survival but will most likely not eliminate the cancer. The first group of treatments includes transplantation, surgery, thermal ablation, and percutaneous alcohol injections. These treatments are generally recommended when the tumor has been found at an early stage. Many doctors will not use these treatments if the tumor is larger than 5 cm.

Descriptions of the most common treatment options, both disease-directed and those aimed at managing side effects and symptoms, are listed below. Take time to learn about your treatment options and be sure to ask questions about things that are unclear. Also, talk about the goals of each treatment with your doctor and what you can expect while receiving the treatment. Learn more about making treatment decisions.

Disease-directed treatments aimed at eliminating HCC

Surgery

Surgery is the removal of the tumor and surrounding tissue during an operation. It is likely to be the most successful disease-directed treatment, particularly for patients with a small tumor (smaller than 5 cm). A surgical oncologist is a doctor who specializes in treating cancer using surgery.

Two types of surgery are used to treat HCC. The part of the liver with the cancer may be removed in a hepatectomy, or a liver transplantation may be done. Both procedures are described below. However, if the tumor has spread outside the liver, or if the patient has other serious illnesses, surgery may not be an option.

Hepatectomy. When a portion of the liver is removed, the surgery is called a hepatectomy. A hepatectomy can be done only if the cancer is in one part of the liver, and the liver is working well. The remaining section of liver takes over the functions of the entire liver and may regrow to its normal size within a few weeks. A hepatectomy may not be possible if the patient has advanced cirrhosis even if the tumor is small.

The side effects of a hepatectomy may include pain, weakness, and fatigue, and a temporary liver failure. The health care team will watch for signs of bleeding, infection, liver failure, or other problems that need immediate treatment. Learn more about cancer surgery.

Liver transplantation. Sometimes, a liver transplantation can be done. This procedure is possible only when the cancer has not spread out of the liver, a suitable donor is found, and very specific criteria are met.

After a transplant, the patient will be watched closely for signs that the body might be rejecting the new liver or that the tumor has come back. The patient must take medication to prevent rejection, and the drugs can have side effects, such as puffiness in the face, high blood pressure, or increased body hair.

Liver transplantation is a particularly effective treatment for people with a small tumor because transplantation removes the tumor and the damaged liver. However, there are few donors, and people waiting for a liver transplant may have to wait a long time before a liver becomes available. During this time, the disease may get worse. The transplant center will advise you how long the wait is likely to be and what rules are used to prioritize people on the waiting list.

Thermal ablation

Radiofrequency ablation (RFA) and microwave therapy both use heat to destroy cancer cells. It may be given through the skin, through laparoscopy, or during a surgical operation while a patient is sedated.

Percutaneous ethanol injection

Percutaneous ethanol injection uses alcohol injected directly into the liver tumor to destroy it. Side effects include fever and pain after the procedure, but the procedure is generally very simple, safe, and particularly effective for a tumor smaller than 3 cm. If the alcohol escapes from the liver, however, a person may have brief but severe pain. This option is currently being used less often and has been largely replaced by radiofrequency ablation (see above).

Disease-directed treatments aimed at improving survival

If the doctor determine that the cancer cannot be eliminated using one of the treatment options listed above, he or she may recommend one of the following to shrink the tumor and/or slow tumor growth. While these treatments will most likely not get rid of the cancer completely, they have been shown to improve survival.

Chemoembolization. This is a type of chemotherapy treatment in which drugs are injected into the hepatic artery (similar to hepatic arterial infusion, see below) and then the flow of blood through the artery is blocked for a short time so the chemotherapy stays in the tumor longer. Blocking the blood supply to the tumor also kills cancer cells. Two clinical trials have provided evidence that this treatment can increase survival for some patients. In addition to being used as a primary treatment for HCC, chemoembolization may be used to slow tumor growth for people who are on the waiting list for liver transplantation.

Radiation therapy. Radiation therapy is the use of high-energy x-rays or other particles to destroy cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a set period of time. External-beam radiation therapy is radiation given from a machine outside the body. External-beam radiation therapy is not often used for HCC. However, internal radiation therapy, which involves placing radioactive beads into the artery that supplies the tumor with blood in a manner similar to chemoembolization, is becoming more widely used in the United States (see above).

Depending on the type of radiation therapy used, your doctor will explain ways to help protect your other organs from radiation during treatment and the side effects that may be expected. The general side effects from radiation therapy may include fatigue, mild skin reactions, upset stomach, and loose bowel movements. Most side effects go away soon after treatment is finished. For internal radiation therapy, the side effects may include damage to the stomach and lungs. However, these can often be avoided by special pre-treatment preventive measures. Learn more about radiation therapy.

Targeted therapy. Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Recent studies show that not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. As a result, doctors can better match each patient with the most effective treatment whenever possible. In addition, many research studies are taking place now to find out more about specific molecular targets and new treatments directed at them. Learn more about targeted treatments.

For HCC, anti-angiogenesis drugs are the most common targeted therapy. Anti-angiogenesis therapy is focused on stopping angiogenesis, which is the process of making new blood vessels. Because a tumor needs the nutrients delivered by blood vessels to grow and spread, the goal of anti-angiogenesis therapies is to “starve” the tumor. This is one of the ways sorafenib (Nexavar) is thought to work. Sorafenib is one of the treatments for advanced HCC that cannot be completely removed with surgery. It is given orally (by mouth). Talk with your doctor about the possible side effects for a specific medication and how they can be managed. The side effects of sorafenib include diarrhea and certain skin problems.

Other treatment options

Chemotherapy. Chemotherapy is the use of drugs to destroy cancer cells, usually by stopping the cancer cells’ ability to grow and divide. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. A chemotherapy regimen usually consists of a specific number of cycles given over a set period of time. A patient may receive one drug at a time or combinations of drugs at the same time. Chemotherapy for HCC may be given in the two ways described below:

  • Systemic chemotherapy treatment: Systemic chemotherapy is delivered through the bloodstream to reach cancer cells throughout the body. Systemic chemotherapy is typically given through an intravenous (IV) tube placed into a vein using a needle, but it can also be given as a pill or capsule that is swallowed (orally).
  • Regional chemotherapy treatment: A small pump is surgically placed in the body to deliver chemotherapy directly to the blood vessels that feed the tumor.

Chemotherapy is less widely used nowadays for HCC. The side effects of chemotherapy depend on the individual and the dose used, but they can include nausea and vomiting, hair loss, loss of appetite, diarrhea, fatigue, low numbers of blood cells, bleeding or bruising after minor cuts or injuries, numbness and tingling in the hands or feet, headaches, hair loss, and darkening of the skin and fingernails. These side effects usually go away once treatment is finished.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Cryosurgery. This treatment uses extreme cold to freeze and kill cancer cells.

Hepatic arterial infusion. Hepatic arterial infusion uses an anticancer drug injected into a catheter that has been placed in the major artery supplying blood to the liver. This treatment is a type of chemotherapy, but it does not have as many side effects.

Immunotherapy. Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function. Side effects of biologic therapy are similar to the flu and can include fatigue, fever, chills, muscle pain, and headache. Learn more about immunotherapy.

In addition to the treatment options described above, the doctor may suggest that the patient enroll in a clinical trial, which is a research study that evaluates new treatments.

Getting care for symptoms and side effects

Cancer and its treatment often cause side effects. In addition to treatment to slow, stop, or eliminate the cancer, an important part of cancer care is relieving a person’s symptoms and side effects. This approach is called palliative or supportive care, and it includes supporting the patient with his or her physical, emotional, and social needs.

Palliative care can help a person at any stage of illness. People often receive treatment for the cancer and treatment to ease side effects at the same time. In fact, patients who receive both often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, and other therapies. You may also receive palliative treatments similar to those meant to eliminate the cancer, such as chemotherapy, surgery, and radiation therapy. Talk with your doctor about the goals of each treatment in your treatment plan.

Before treatment begins, talk with your health care team about the possible side effects of your specific treatment plan and supportive care options. And during and after treatment, be sure to tell your doctor or another health care team member if you are experiencing a problem so it is addressed as quickly as possible. Learn more about palliative care.

Metastatic HCC

If cancer has spread to another location in the body, it is called metastatic cancer. People with this diagnosis are encouraged to talk with doctors who are experienced in treating this stage of cancer, because there can be different opinions about the best treatment plan. Learn more about seeking a second opinion before starting treatment, so you are comfortable with the treatment plan chosen. This discussion may include clinical trials studying new treatments.

Your health care team may recommend a treatment plan that includes a combination of chemotherapy (including sorafenib, see Targeted therapy above), radiation therapy, and/or other options. At this stage, the goal of treatment is typically not to cure the cancer but to slow its growth. Supportive care will also be important to help relieve symptoms and side effects.

For most patients, a diagnosis of metastatic cancer is very stressful and, at times, difficult to bear. Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other patients, including through a support group.

Remission and the chance of recurrence

A remission is when cancer cannot be detected in the body and there are no symptoms. This may also be called “no evidence of disease” or NED.

A remission can be temporary or permanent. This uncertainty leads to many survivors feeling worried or anxious that the cancer will come back. While many remissions are permanent, it’s important to talk with your doctor about the possibility of the cancer returning. Understanding the risk of recurrence and the treatment options may help you feel more prepared if the cancer does return. Learn more about coping with the fear of recurrence.

If the cancer does return after the original treatment, it is called recurrent cancer. It may come back in the same place (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a cycle of testing will begin again to learn as much as possible about the recurrence, including whether the cancer’s stage has changed. After testing is done, you and your doctor will talk about your treatment options. Often the treatment plan will include the therapies described above, such as surgery, chemotherapy, and radiation therapy, but they may be used in a different combination or given at a different pace. Your doctor may also suggest clinical trials that are studying new ways to treat this type of recurrent cancer.

People with recurrent cancer often experience emotions such as disbelief or fear. Patients are encouraged to talk with their health care team about these feelings and ask about support services to help them cope. Learn more about dealing with cancer recurrence.

If treatment fails

Recovery from cancer is not always possible. If treatment is not successful, the disease may be called advanced or terminal cancer.

This diagnosis is stressful, and this is difficult to discuss for many people. However, it is important to have open and honest conversations with your doctor and health care team to express your feelings, preferences, and concerns. The health care team is there to help, and many team members have special skills, experience, and knowledge to support patients and their families. Making sure a person is physically comfortable and free from pain is extremely important.

Patients who have advanced cancer and who are expected to live less than six months may want to consider a type of palliative care called hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to think about where you would be most comfortable: at home, in the hospital, or in a hospice environment. Nursing care and special equipment can make staying at home a workable alternative for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.  

Liver Cancer - About Clinical Trials

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. To see other pages, use the menu on the side of your screen.

Doctors and scientists are always looking for better ways to treat patients with HCC. To make scientific advances, doctors create research studies involving volunteers, called clinical trials. The number of clinical trials focused on HCC has increased in recent years.  

Many of these clinical trials are focused on new treatments, evaluating whether a new treatment is safe, effective, and possibly better than the current (standard) treatment. These types of studies evaluate new drugs, different combinations of existing treatments, new approaches to radiation therapy or surgery, and new methods of treatment. Patients who participate in clinical trials are often among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment.

There are also clinical trials that study new ways to ease symptoms and side effects during treatment and managing the late effects that may occur after treatment. Talk with your doctor about clinical trials regarding side effects. In addition, there are ongoing studies about ways to prevent the disease.

Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that these studies are the only way to make progress in treating HCC. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with HCC.

Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different from the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

For specific topics being studied for liver cancer, learn more in the Latest Research section.

Patients who participate in a clinical trial may stop participating at any time for any personal or medical reason. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that patients participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if the patient chooses to leave the clinical trial before it ends.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer.

The next section helps explain the areas of research going on today about this type of cancer. Use the menu on the side of your screen to select Latest Research, or you can select another section, to continue reading this guide.  

Liver Cancer - Latest Research

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will read about the scientific research being done now to learn more about this type of cancer and how to treat it. To see other pages, use the menu on the side of your screen.

Doctors are working to learn more about HCC, ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the diagnostic and treatment options best for you.

Cancer vaccines. These are treatments that may help the patient's immune system recognize and attack HCC cells. Sometimes the vaccine is given with an immune system stimulant, such as sargramostim (Leukine, Prokine).

Combination chemotherapy. Different drugs destroy cancer cells in different ways. Using a combination of drugs can increase the chance more cancer cells will be killed; many times one drug will help the other drug work better.

Combining therapies. Researchers are looking into whether combining treatments, such as RFA and chemoembolization, is more effective than using these treatments separately.

Anti-angiogenesis drugs. In addition to sorafenib (see the Treatment Options section), several other anti-angiogenic agents are being tested in clinical trials.

Greater use of liver transplantation. The possibility of expanding the criteria for liver transplantation is being studied for HCC, which would make more patients eligible for the procedure.

Gene therapy. This new treatment changes a gene to fight cancer. Although gene therapy is in the very early stages of development, some clinical trials are already underway. In one example, the new gene makes chemotherapy work better. In this type of treatment, a gene can be directly injected into the tumor. The doctor then gives the patient the inactive drug and this new gene helps activate the drug in the tumor. These and the targeted therapy sorafenib (see the Treatment Options section) are being tested in combination with other treatments as listed above.

Supportive care. Clinical trials are underway to find better ways of reducing symptoms and side effects of current HCC treatments in order to improve patients’ comfort and quality of life.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding liver cancer, explore these related items that take you outside of this guide:

The next section addresses how to cope with the symptoms of the disease or the side effects of its treatment. Use the menu on the side of your screen to select Coping with Side Effects, or you can select another section, to continue reading this guide.  

Liver Cancer - Coping with Side Effects

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find out more about steps to take to help cope with physical, social, and emotional side effects. This page includes several links outside of this guide to other sections of this website. To see other pages, use the menu on the side of your screen.

Fear of treatment side effects is common after a diagnosis of cancer, but it may help to know that preventing and controlling side effects is a major focus of your health care team. This is called palliative or supportive care, and it is an important part of the overall treatment plan, regardless of the stage of disease.

Common side effects from each treatment option for HCC are described in detail within the Treatment Options section. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. Side effects depend on a variety of factors, including the cancer’s stage, the length and dosage of treatment(s), and your overall health.

Before treatment begins, talk with your doctor about possible side effects of each type of treatment you will be receiving. Ask which side effects are most likely to happen, when they are likely to occur, and what can be done to prevent or relieve them. And, ask about the level of caregiving you may need during treatment and recovery, as family members and friends often play an important role in the care of a person with HCC. Learn more about caregiving.

In addition to physical side effects, there may be emotional and social effects as well. Patients and their families are encouraged to share their feelings with a member of their health care team who can help with coping strategies, including concerns about managing the cost of your cancer care.

During and after treatment, be sure to tell the health care team about the side effects you experience, even if you feel they are not serious. Sometimes, side effects can last beyond the treatment period, called a long-term side effect. A side effect that occurs months or years after treatment is called a late effect. Treatment of both types of effects is an important part of survivorship care. Learn more about late effects or long-term side effects by reading the After Treatment section or talking with your doctor.

The next section helps explain medical tests and check-ups needed after finishing cancer treatment. Use the menu on the side of your screen to select After Treatment, or you can select another section, to continue reading this guide.  

Liver Cancer - After Treatment

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will read about your medical care after cancer treatment is finished and why this follow-up care is important. To see other pages, use the menu on the side of your screen.

After treatment for HCC ends, talk with your doctor about developing a follow-up care plan. This plan will include regular physical examinations, imaging tests (such as ultrasound), and blood tests to monitor your recovery for the coming months and years.

ASCO offers cancer treatment summary forms to help keep track of the cancer treatment you received and develop a survivorship care plan once treatment is completed.

Careful follow-up care is important no matter what type of treatment was used. Follow-up care will not only measure how effective the treatment has been but also allow early detection of any recurrence. This is particularly important because there is always a risk that the tumor will come back after treatment or that another tumor will develop. Research to find ways to prevent second cancers and recurrent HCC is ongoing, but there is no standard prevention method at this time.

People recovering from HCC are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help you rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about the next steps to take in survivorship, including making positive lifestyle changes.

The next section offers a list of questions you may want to ask. Use the menu on the side of your screen to select Questions to Ask the Doctor, or you can select another section, to continue reading this guide.  

Liver Cancer - Questions to Ask the Doctor

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find some questions to ask your doctor or other members of your health care team, to help you better understand your diagnosis, treatment plan, and overall care. To see other pages, use the menu on the side of your screen.

Talking often with the doctor is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment, or download Cancer.Net’s free mobile app for an e-list and other interactive tools to manage your care.

General questions

  • What is my diagnosis? What is the exact type of liver cancer?
  • What is the size of the tumor?
  • What is the stage of my cancer? What does this mean?
  • Can the tumor be removed surgically? What does this mean?
  • Can you explain my pathology report (laboratory test results) to me?
  • Am I a carrier of hepatitis B or C? What does this mean?
  • Do I have cirrhosis of the liver? What does this mean?
  • Do I have NAFLD? What does this mean?
  • What are my treatment options?
  • What clinical trials are open to me? Where are they located, and how do I find out more about them?
  • What treatment plan do you recommend? Why?
  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?
  • What are the chances for success with the planned treatment?
  • Do I need treatment right away?
  • Who will be part of my health care team, and what does each member do?
  • Who will be coordinating my overall treatment and follow-up care?
  • What are the possible side effects of this treatment, both in the short term and the long term?
  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?
  • Could this treatment affect my sex life? If so, how and for how long?
  • Could this treatment affect my ability to become pregnant or have children? If so, should I talk with a fertility specialist before cancer treatment begins?
  • If I’m worried about managing the costs related to my cancer care, who can help me with these concerns?
  • What support services are available to me? To my family?
  • Whom should I call for questions or problems?

For patients who need surgery

  • How much of my liver will be removed?
  • Will I need a liver transplant?
  • If I need a liver transplant, am I likely to be prioritized on the transplant waiting list? How long should I expect to wait?
  • Will I need to stay in the hospital for this surgery? If so, for how long?
  • What are the possible side effects of my surgery, in the short term and the long term?

For patients who need chemotherapy/targeted therapy/immunotherapy

  • What type of therapy will I be receiving?
  • How will it be delivered (through an IV, a catheter, or a pill)?
  • What does the preparation for this treatment involve?
  • What short- and long-term side effects can I expect from this treatment?
  • What can be done to manage these side effects?

For patients who need radiation therapy or other types of treatment

  • What type of treatment is recommended?
  • What is the goal of this treatment?
  • How long will it take to give this treatment?
  • What side effects can I expect from this treatment?
  • What can be done to relieve the side effects?

After treatment

  • What are the chances that the tumor will return?
  • What follow-up tests do I need, and how often do I need them?

The next section offers some more resources that may be helpful to you. Use the menu on the side of your screen to select Additional Resources, or you can select another section, to continue reading this guide.  

Liver Cancer - Additional Resources

This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/2014

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Liver Cancer. To go back and review other pages, use the menu on the side of your screen.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer, both for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond. Here are a few sections that may get you started in exploring the rest of Cancer.Net:

 This is the end of Cancer.Net’s Guide to Liver Cancer. Use the menu on the side of your screen to select another section, to continue reading this guide.